SMI Clients- Clients Exam and Survey-Follow-up

Primary and Behavioral Health Care Integration Program

0990-0371Attach 6 Client exam and survey

SMI Clients- Clients Exam and Survey-Follow-up

OMB: 0930-0340

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Form Approved

OMB No. 0990-0371

Exp. Date XX/XX/20XX


ATTACHMENT 6


CLIENT PHYSICAL EXAM AND SURVEY




SECTION 1: PHYSICAL EXAM


Format

  • Brief physical exam conducted by external contractor


Content

Primary

  • Blood pressure: systolic and diastolic. Measured with digital sphygmomanometer

  • BMI:

    • Weight (kg) – measured with standard medical scale

    • Height (cm) – measured with measuring stick built into standard medical scale

  • HgbA1c or blood sugar: from blood sample – finger stick

  • Total Cholesterol: from blood sample – finger stick

  • HDL: from blood sample – finger stick

  • LDL: from blood sample – finger stick

  • Triglycerides: from blood sample – finger stick

Secondary

  • Waist circumference

  • Breath CO (ppm) for smoking status








PBHCI Program


Patient Survey








PAGE LEFT BLANK


INSTRUCTIONS


  • You can use a pen or a pencil.

  • All of your answers will be kept private and confidential.

  • You can skip any questions that make you feel uncomfortable.

  • Fill in the circle next to your answer or write your answer in the box provided.






MY OPINIONS



In order to provide the best possible mental health and related services, we need to know what you think about how well you were able to deal with your everyday life during the past 30 days.


Please tell us how much you disagree or agree with each of the following:


1. I deal effectively with daily problems. (shade one circle)

Strongly disagree

Disagree

Agree

Strongly agree



2. I am able to control my life. (shade one circle)

Strongly disagree

Disagree

Agree

Strongly agree



3. I am getting along with my family. (shade one circle)

Strongly disagree

Disagree

Agree

Strongly agree



4. My housing situation is OK with me. (shade one circle)

Strongly disagree

Disagree

Agree

Strongly agree



5. My symptoms are not bothering me. (shade one circle)

Strongly disagree

Disagree

Agree

Strongly agree




MY USE OF TOBACCO, ALCOHOL AND DRUGS


6. In the past 30 days, how often have you used tobacco products, such as cigarettes, chewing tobacco, cigars, etc. (shade one circle)

Never

Once or twice

Weekly

Daily or almost daily


7. How soon after waking do you smoke your first cigarette of the day? (shade one circle)

I don’t smoke cigarettes

5 minutes or less

Between 6 and 30 minutes

More than 60 minutes



8. How many cigarettes do you smoke per day? (shade one circle)

I don’t smoke cigarettes

More than 30

Between 21 and 30

Between 11 and 20

Less than 10



9. In the past 30 days, how often have you used alcoholic beverages, such as beer, wine, liquor, etc.? (shade one circle)

Never

Once or twice

Weekly

Daily or almost daily



10. How many times in the past 30 days have you had four or more alcoholic drinks in a day? By “a drink” we mean a can of beer, glass of wine, or shot of liquor. (shade one circle)

Never

Once or twice

Weekly

Daily or almost daily



11. How many times in the past 30 days have you had five or more alcoholic drinks in a day? By “a drink” we mean a can of beer, glass of wine, or shot of liquor. (shade one circle)

Never

Once or twice

Weekly

Daily or almost daily




12. In the past 30 days, how often have you used an illegal drug, like marijuana, cocaine, heroin, etc., to get high? (shade one circle)

Never

Once or twice

Weekly

Daily or almost daily



13. In the past 30 days, how often have you used a prescription drug, like Xanax, Valium, Oxycodone, Percocet, etc., for some purpose other than to treat a medical or mental health condition? (shade one circle)

Never

Once or twice

Weekly

Daily or almost daily




14. In the past 30 days, how many times have you been arrested? (shade one circle)

0 in the past 30 days

1 time in the past 30 days

2 times in the past 30 days

3 times in the past 30 days

More than 3 times, please write the number here: ________


MY EXPERIENCES


15. Staff here believe that I can grow, change and recover. (shade one circle)

Strongly disagree

Disagree

Undecided

Agree

Strongly agree




16. Staff helped me obtain the information I needed so that I could take charge of managing my illness. (shade one circle)

Strongly disagree

Disagree

Undecided

Agree

Strongly agree




17. I, not staff, decided my treatment goals. (shade one circle)

Strongly disagree

Disagree

Undecided

Agree

Strongly agree




18. If I had other choices, I would still get services from this agency. (shade one circle)

Strongly disagree

Disagree

Undecided

Agree

Strongly agree




19. I am happy with the friendships I have. (shade one circle)

Strongly disagree

Disagree

Undecided

Agree

Strongly agree



20. I have people with whom I can do enjoyable things. (shade one circle)

Strongly disagree

Disagree

Undecided

Agree

Strongly agree



21. I feel I belong in my community. (shade one circle)

Strongly disagree

Disagree

Undecided

Agree

Strongly agree



22. In a crisis, I would have the support I need from family or friends. (shade one circle)

Strongly disagree

Disagree

Undecided

Agree

Strongly agree




MY HEALTH


The next questions ask how often you have certain types of food available at home.


23. How often do you have fruits available at home? This includes fresh, dried, canned and frozen fruits. (shade one circle)

Always

Most of the time

Sometimes

Rarely

Never



24. How often to you have any dark green vegetables (e.g., spinach, collard greens) at home? This includes fresh, dried, canned, and frozen. (shade one circle)

Always

Most of the time

Sometimes

Rarely

Never



25. How often do you have 1% fat, skim or fat-free milk available at home? Please do not include 2% milk or soy milk. (shade one circle)

Always

Most of the time

Sometimes

Rarely

Never



26. Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time during the past 7 days.

During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (circle one number)

0 1 2 3 4 5 6 7



27. Over the past 30 days, on average how many hours per day did you sit and watch TV, videos or use the computer? (shade one circle)

Less than one hour per day

1 hour per day

2 hours per day

3 hours per day

4 hours per day

5 hours or more per day


28. How would you rate your overall health right now? (shade one circle)

Excellent

Very good

Good

Fair

Poor



29. What kind of place do you usually go to when you are sick or need advice about your health? Is it a clinic, doctor’s office, emergency room, or some other place? (shade one circle)

Clinic or health center

Doctor’s office or HMO

Hospital emergency room

Hospital Outpatient Department

Some other place





30. About how long has it been since you last saw or talked to a doctor or other health care professional about your health? Include doctors seen while you were a patient in a hospital. (shade one circle)

6 months or less

More than 6 months but not more than 1 year ago

More than 1 year but not more than 3 years ago

More than 3 years

Never



31. Do you take prescription drugs on a regular basis? (shade one circle)

Yes

No



32. Do you take three or more prescription drugs on a regular basis? (shade one circle)

Yes

No


33. Do you currently have more than 5 prescription drugs in your medicine cabinet? (shade one circle)

Yes

No



3 4. Do you know how many of your prescription medications are for mental health problems?


Yes write the number in the box:

No



3 5. Do you know how many of your prescription medications are for physical health problems?


Yes write the number in the box:

No



36. Are you on any kind of diet, either to lose weight or for some other health-related reason? (shade one circle)

Yes

No





37. In the last 30 days, what services have you used? (check each box that applies)

Medical care

Employment services

Family services

Child care

Transportation

Education services

Housing support

Social recreational activities

Consumer operated (peer) services

HIV testing



ABOUT ME



38. What is your gender? (shade one circle)

Male

Female

Transgender

Something else



39. Are you Hispanic or Latino? (shade one circle)

Yes

No



40. What race do you consider yourself? (check each box that applies)

Black or African American

Asian

Native Hawaiian or other Pacific Islander

Alaska Native

White

American Indian



41. When were you born? (write the month, the date, and the year in the boxes)






42. What is the highest level of education you have finished, whether or not you received a degree? (shade one circle)

Less than 12th grade

12th grade/High school diploma/equivalent (GED)

Voc/Tech diploma

Some college or university

Bachelor’s degree (BA, BS)

Graduate work/Graduate degree



43. Are you currently enrolled in school or a job training program? (shade one circle)

Not enrolled

Enrolled full time

Enrolled part time

Something else



44. Are you currently employed? (check each box that applies)

Employed full time (35+ hours per week, or would have been)

Employed part time

Unemployed – looking for work

Unemployed – disabled

Unemployed – volunteer work

Unemployed – retired

Unemployed – not looking for work

Something else




45. In the past 30 days, where have you been living most of the time? (shade one circle)

Owned or rented house

Apartment, trailer, room

Someone else’s house, apartment, trailer, room

Homeless (shelter, street/outdoors, park), Group home

Adult foster care

Transitional living facility

Hospital (medical)

Hospital (psychiatric)

Detox/inpatient or residential substance abuse treatment facility

Correctional facility (jail/prison)

Nursing home

VA Hospital

Veteran’s home

Military base

Somewhere else










THANK YOU FOR PARTICIPATING!








Please return your survey

to the staff member who gave it to you


















***Staff Use Only***

Participant ID: __________ Site ID: ________________

Today’s Date: ___/___/___


Questionnaire was completed by: Respondent Interviewer


Survey Version 3-17-11





1

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0371. The time required to complete this information collection is estimated to average 40 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer


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File TitlePBHCI Program Evaluation
AuthorIST
Last Modified ByIST
File Modified2011-07-01
File Created2010-07-28

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